GW1-2022-06759_Well Construction - GW1_20220713

WELL CONSTRUCTION RECORD For Internal Use ONLY:
71iis form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER'7,ONES`.
[..� / Pt• u FROM TO DESCRIPTION
Well Contractor NadSe z ft. / e
ft. ft. � .01
NC Well Contractor Certification Number 15.OUTER CASING for multi-6ised yells OR LINER da licable : '
\,�_ FROM TO DIAMETER THICKNESS MATERIAL
L r,lcc 7.r/ / iY) -. ft. ft in. Y
,7 e
Company Name 16.INNER'CASING OR=TUBING` eothermatclosed=loti
'' II to �1 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:_ � Ad`i 0 ft. ft. in.
List all applicable well construction permits(i.e.Counny.Stare,Variance,etc.) '
-- ft ft. i in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICIQVESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft.
❑Geothermal(Heating/Cooling Supply) Oresidendal Water Supply(single) ft ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation ft fr. a �e
Non-Water Supply Well: ft. fL
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK if.a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑Aquifer Test ❑StormwaterDminage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING:LOG nittneti'sdditional stieets:if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sollfrock .e ruin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. 0 ft
'J ti
tt ft a
4.Date Well(s)Completed:
ft ft
S.Well Locations
�rona]OL' l LAB-e.�.n S-&S&L ft at sec f
Facility/Owner Name Facility ID#(if applicable) t pyft. ft. .l D 1�'� '� p
e7.5S e v/)11 -AP OCLA Rd• fL fL
Physical Address,City,and Zip
21.REMARKS- 7.
►Itll t:..t
County Parcel Identification No.(PIN) •;�, ra a,3•�t ;r � t��!r'1 I'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat(long is sufficient)
�.7 a SS / N ©e 20 62,20 W 2� 1?6-,U. y
b V,22
Signature of Cer fled Well Contractor Date
6.Is(are)the well(s): urfr1r1anent or ❑Temporary By signing this foray,I hereby certify that the well(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 a•ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or io copy of this record has been provided to the well owner.
If this is a repair,fill oat Awomi well construction i formation and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use die back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple hyection or non-wafer supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 3 ©o (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivells list all depths ifdiIferent(erample-3©200'and 2@100) construction to the following: I
10.Static water level below top of casing: 3 (ft.) Division of Water Quality,Information Processing Unit,
if water level is above casing,use"+^ / 1617 Mail Service,Center,Raleigh,NC 276994617
I ,
11.Borehole diameter: (in.) 24b.For Iniection Wells: In,'addition to sending the form to the address in 24a
Q�G!"c above, also submit a copy of:th,'is form within 30 days of completion of well
12.Well construction method: / construction to the following:
(i.e.auger,rotary,cable,direct pusb,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: p 7 Jt/ 24c.For Water Sunaly&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
t 1 completion of well construction Ito the county health department of the county
13b.Disinfection type: Amount: where constructed.